G. Richard O'Connor

Vogt-Koyanagi-Harada Syndrome

We studied 51 patients who developed Vogt-Koyanagi-Harada (V-K-H) syndrome after corticosteroid therapy. The final visual acuity was better than 6/15 (20/50) in 50%, and less than 6/60 (20/200) in 25% of the patients. The severity and extraocular manifestations of this disease also appeared to be less than observed in patients before the clinical use of corticosteroids. Corticosteroid therapy probably altered the clinical picture in this disease, although other possibilities, including a skewed patient population, may account for these differences.

Factors Related to the Initiation and Recurrence of Uveitis: XL Edward Jackson Memorial Lecture

Uveitis comprises a complex group of diseases in which morbidity may depend on the nature of the initial inflammation as well as on the genetic, hormonal, and emotional background of the patient. Uveitis is initiated in every instance by some form of tissue injury. This may occur as an attack on individual cells by organisms such as Toxoplasma gondii or Herpesvirus hominis. Autoimmune disease may be produced as a late result of microbe-induced injury. The development of specific forms of autoimmunity seems to be dependent upon genetic as well as hormonal factors, particularly estrogens. Tissue injury of immunologic origin takes several forms, such as cytotoxic damage from sensitized lymphocytes, immune complex-mediated injury, and injury from the oxidative products of inflammatory cells. In some cases, permanent alteration of uveal vascular permeability results. Recurrent uveitis may be attributed in some instances to the reappearance of infectious organisms in the target tissue. In other cases, recurrence of inflammation may be attributed to the localization of immune complexes in the uveal tract. Changes in immunoregulation can be attributed to pregnancy, aging, and emotional factors. Neurohumoral pathways related to stress-mediated changes in immunoregulation have recently been described in laboratory animals. These pathways may be linked with stress-related recurrences of uveitis in humans.

Treatment of Ocular Toxoplasmosis with Clindamycin and Sulfadiazine

Seventeen patients with active toxoplasmic retinochoroiditis were treated for four weeks, seven with clindamycin alone and ten with a combination of clindamycin and sulfadiazine. The follow-up period ranged from six months to four years. Results of the Sabin-Feldman dye test were positive in all patients. Five of the seven patients treated with clindamycin alone showed improvement two weeks after treatment was begun, while eight of the ten patients treated with combined clindamycin and sulfadiazine showed both subjective and objective improvement within ten days and signs of healing within three weeks. Since clindamycin and sulfadiazine operate on unrelated metabolic pathways of Toxoplasma, they may act synergistically. A regimen consisting of this combination may be appropriate for the treatment of ocular toxoplasmosis.

The Role of Hypersensitivity Reactions to Toxoplasma Antigens in Experimental Ocular Toxoplasmosis in Nonhuman Primates

To assess the role of ocular hypersensitivity reactions to Toxoplasma antigens in previously sensitized ocular tissues, we used a nonhuman primate model of ocular toxoplasmosis. Each eye of eight monkeys was inoculated with living Toxoplasma organisms into the inner retinal layers. All eyes developed necrotizing retinochoroiditis. Healing of the lesion occurred with the formation of a retinochoroiditic scar. Four months later, Toxoplasma antigens were injected through the right internal carotid artery. Four weeks after this, Toxoplasma antigens were inoculated into the left retina. Iritis, vitritis, and retinal edema occurred in response to the administration of the antigens, but no recurrent necrotizing retinochoroiditis was produced in this model. These findings suggested that hypersensitivity to Toxoplasma antigens does not play a major role in triggering recurrences of toxoplasmic retinochoroiditis in nonhuman primates.

Anterior Uveitis in Geographic or Serpiginous Choroiditis

A 51-year-old man and a 45-year-old man had geographic or serpiginous choroiditis and anterior uveitis as shown by ophthalmoscopy and fluorescein angiography. Anterior uveitis, a previously undescribed feature of this disease, was found in both patients. Despite clear-cut evidence of inflammatory disease, corticosteroid therapy generally proved to be ineffective.

Recurrent herpes simplex uveitis in humans

Herpetic uveitis in man is generally, although not always, a complication of chronic stromal disease of the cornea. It is characterized by pain, photophobia, and redness, and may be abrupt in onset, particularly in recurrent cases. It is often accompanied by a severe secondary glaucoma. Various theories of the pathogenesis are discussed. The weight of experimental evidence favors the proliferation of living virus in the uveal tissues as the cause of the inflammation, although the virus has been isolated only rarely from aspirated aqueous humor. Autoimmune factors must be considered. Cyclopegia is the most important element of treatment, most cases being self-limited and non-destructive. Secondary glaucoma sometimes poses a serious problem that must be treated by radical measures. Antiviral medications such as adenine arabinoside may play an important role in the treatment of resistant cases. Corticosteroid therapy is to be avoided, if possible.

Secondary Syphilis with Iris Papules

A 30-year-old man developed bilateral iridocyclitis with iris roseolae and papules three months after the rash of secondary syphilis. The inflammation resolved after treatment with penicillin, intramuscularly, topically given corticosteroids, and cycloplegics. The serum immune-complex levels were slightly increased. Iris angiography showed leakage of fluorescein in the region of the papules and roseolae and from the vessels of the pupillary margin. When the eye was clinically uninflamed, a follow-up angiogram showed leakage of fluorescein from the same areas, suggesting that the inflammatory effect on the iris vessels persisted in the region of the roseolae, the papules, and the sphincter vessels.

Possible Foreign Body Granuloma of the Retina Associated With Intravenous Cocaine Addiction

A 27-year-old man who was a heroin addict had light flashes in front of the right eye and a hemicentral scotoma immediately after intravenous cocaine. The initial ophthalmoscopic appearance was of a white foreign body lying over the papillomacular bundle of the retina in the right eye. This ophthalmoscopic finding was consistent with intraocular talc, cornstarch, or lactose, common diluting agents that are present in intravenous injections of heroin, cocaine, or methylphenidate hydrochloride, and are known to cause systemic embolic phenomena in chronic drug abusers. This glistening crystal on the surface of the retina changed and evolved into a noninfectious but inflammatory organization of retinal granuloma, in which the foreign body crystal could still be visualized at the apex of the lesion. The anterior and posterior segments of the eye remained free of inflammatory signs throughout the course of the organization of the retinal granuloma.

Toxoplasma Uveitis Without Retinochoroiditis

Excerpt To the editor: We have read with interest the recent correspondence (1) reporting a presumptive anterior uveitis without apparent retinochoroiditis in acquired toxoplasmosis. Although there...

Clindamycin and Toxoplasmosis-Reply

In Reply. —I reviewed with interest the letter that Drs. Parver and Lincoff wrote concerning our article on the use of clindamycin in the treatment of experimentally induced ocular toxoplasmosis. It was gratifying to note that these retinal detachment surgeons observed no adverse effects from the injection of 0.75 ml of clindamycin (150 mg/ml) under the capsule of Tenon at the conclusion of their operative procedures. In a subsequent series of experiments performed by us and accepted for publication in theArchives, we found that subconjunctival injections of 1.0 ml of clindamycin (150 mg/ml) into the anterior segment of the rabbit eye produced severe hyperemia and chemosis of the conjunctiva as well as lid swelling and edema of the subjacent cornea. No such irritation or toxic effects were noted when the material was first diluted so as to contain only 50 mg/ml. Although the results of experiments performed on rabbits